Provider Demographics
NPI:1043534159
Name:HANNA, MARIAM G (DDS)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:G
Last Name:HANNA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 CAMINITO ARDIENTE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7134
Mailing Address - Country:US
Mailing Address - Phone:817-846-2424
Mailing Address - Fax:
Practice Address - Street 1:1711 CAMINITO ARDIENTE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7134
Practice Address - Country:US
Practice Address - Phone:817-846-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA62786122300000X
LA6125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program